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Sample Background Check Release
AUTHORIZATION FOR RELEASE OF INFORMATION
Due to the nature of its business (NAME OF PREMISE) requires a background check on its
employees.
My name is
LAST
FIRST
My social security #:
MIDDLE
Sex:
Place of birth:
Date of Birth:
Present address
City, State, Zip:
M
F
I
, Social Security #
, authorize
(NAME OF PREMISE) TO CONDUCT A BACKGROUND CHECK on me that may include
access to CRIMINAL, CREDIT, CIVIL AND TRAFFIC records. I authorize a full review and
complete disclosure of all records of all agencies by/to any duly authorized agent of (NAME OF
PREMISE) whether the said reports are public or private and including those, which may be
deemed to be of a privileged or confidential nature. I understand this information is as listed in
the records, and by accessing information this company is not liable for its content or accuracy. I
agree to indemnify and hold harmless the person to whom this request is presented, their agents
and employees, from an